SPECIAL ARTICLES

Psychosocial Risk Factors for Suicide

Soyoung Irene Lee, M.D., Ph.D., Han-Yong Jung, M.D., Ph.D.

Department of Psychiatry and Soonchunhyang University Bucheon Hospital, College of Medicine, Soonchunhyang
University

ponent of a suicide risk assessment. Familial,

Abstract
social and environmental factors must be under-
Objective: There is little information as to the stood in a comprehensive context along with
social or environmental correlates to human the psychiatric disorder and the biological vul-
suicidal behavior. Thus, the purpose of this nerability.
overview was to investigate and review the psy-
chosocial correlates that are suggested to medi- Key words: Suicide, Social, Environmental,
ate suicidal behaviors. Method: A literature Psychoso-cial, Risk factors.

search was conducted on suicide and its risk, [ Psychiatry Invest 2006; 3 (2):15-22]
risk factors, population characteristics, and pre-
diction. Thereafter, articles dealing with famil-
ial, social and environmental characteristics as Introduction
risk factors for suicidal behavior are summa-
The increasing rate of suicide and suicidal
rized in a review which is written in a narrative
attempt is a growing health problem worldwide.
manner. Results: Risk factors for suicide occur-
In 2003, the rate of suicide completers was 25.2
ring from the interaction between the individual
per 100,000 in Korea.1 The suicide mortality rate
and family context (abuse, loss, family discord)
reported in 2003 was 137% higher than that
and those occurring from the interaction
reported 10 years earlier, and suicide was the 2nd
between the individual and his or her larger
leading cause of mortality, particularly among
environmental context (stressful life events,
youths aged 15 to 19 years. The rate of suicide
social influence and support) are presented.
attempts was also found to be remarkably high:
Conclusions: This overview provides a summa-
1.01% for women and 0.82% for men.2 This is an
ry of the recognized psychosocial risk factors
alarmingly high prevalence rate. Thus, under-
for suicidal behavior. It is revealed that the psy-
standing the risk factors for suicide and/or suici-
chosocial characteristics are a necessary com-
dal attempt is very important for mental health
professionals. Suicidal behavior occurs in
Correspondence: Han-Yong Jung, M.D., Ph.D., Department
response to interactions between biological, psy-
of Psychiatry, Soonchunhyang University Bucheon Hospital,
1174 Jung-dong, Wonmi-gu, Bucheon, Gyeonggi-do, Korea chological, and socio-environmental risk factors,
(420-767) along with the relative absence of protective fac-
Tel: +82-32-621-5017, Fax: +82-32-621-5018,
E-mail: hanyjung@schbc.ac.kr tors. 3 Most studies purporting to elicit the risk

15
 Suicide and psychosocial factors

factors for suicide, for example those involving fied. Articles in the Korean language were
psychological autopsies, have focused on the searched for in the KoreaMed database (http://
evaluation of pathological mental status or psy- www.koreamed.org/SearchBasic.php) using sui-
chiatric disorders as potential risk factors. cide as a search term. From this initial selec-
Information about the social and environmental tion, the eligibility for inclusion in this review
correlates for suicide and/or suicidal attempt is was determined by reading the abstracts of the
relatively scarce. 4 There is continuing debate individual articles. Relevancy to the purpose of
over the relative importance of socio-environ- this review was defined as the inclusion of the
mental risk factors as compared to psychiatric following descriptors or concepts: risk, risk fac-
diagnostic factors in explaining suicidal behav- tors, population characteristics, or prediction.
ior. 5 However, since the identification of those Finally, 43 articles in English and 8 in the
with a greater risk for further attempts among the Korean language were obtained and reviewed in
large number of people exhibiting suicidal full text.
behaviors is the most crucial aspect in such an
assessment, it is necessary for mental health pro-
Results
fessionals to understand every possible risk fac-
tor. Abuse
Thus, the major purpose of this study was to The articles in the literature generally support
investigate the psychosocial risk factors for sui- the association of adverse life events, such as
cide and/or suicidal attempt by reviewing the p h y s i c a l o r s e x u a l a b u s e , w i t h s u i c i d e . 6 - 11
published research on the social, environmental Sexual abuse, in particular, has received the
and familial factors associated with human sui- most attention. The association between child
cidal behaviors. sexual abuse and suicide has been clearly estab-
lished in several studies. 12-14 In a Dutch cross-
sectional study, suicide attempts were reported
Methods
to be five times more common in girls and 20
A literature search for the psychosocial risk times more common in boys with previous sex-
factors of suicide and suicidal attempt was car- ual abuse in comparison to non-abused adoles-
ried out using the PubMed database (http:// cents. 15 Furthermore, clear evidence confirming
www.ncbi.nlm.nih.gov/entrez/query. fcgi? DB = the link between child sexual abuse and suicide
pubmed). First, a search in the Sys-temic as a subsequent negative effect was provided in
Reviews was conducted using suicide as a a recent meta-analysis. 10 They reported a sub-
search term. As a result, 408 review articles stantial effect of child sexual abuse on suicide
were searched. In addition, a narrow and specif- (Glass’s effect size d = .44). Child sexual abuse
ic search in the Clinical Study Category, limit- was associated with suicide, regardless of the
ing the language to English, and the type of victim’s age, gender, or socioeconomic status,
article to Review, Meta-analysis, or Randomized suggesting that the sexual abuse serves as a life
Controlled Trial; again, the search term was event impacting independently on suicidal
suicide. As a result, 141 articles were identi- behavior.10,16

16
 Lee SI & Jung HY

Family violence, abuse, and neglect have been the patient at the death of his or her parents was
associated with suicidal behavior especially in revealed to be significantly lower in the suicidal
children and adolescents. 6,17 In a prospective group than in the non-suicidal group. A separa-
register based study of Danish children, adoles- tion that reminds one of a similar event in child-
cents who had been hospitalized and profession- hood would also imply an elevated risk for sui-
ally assessed as a result of being battered or cide.
neglected had an increased risk of suicide In addition to the actual loss of a significant
attempts with an odds ratio of 10.0.18 other, threatened losses, loss of health or even
Whether the high prevalence of suicidality is the loss of a national or cultural affiliation are
more specifically related to a history of abuse or suggested to be associated with an increased
is related to a specific consequence of various risk for suicidal behaviors.
types of psychopathology or substance abuse
Family factors
following child abuse is not clear as yet. In the
case of child sexual abuse, a multifaceted model Empirical research suggests that early and
of traumatization 19 is supported rather than a chronic life event stresses, particularly within
specific sexual abuse syndrome leading to sui- the family context, are associated with suicidal
cide behavior. According to this view, the behavior. 4,23,24 Various types of problems in
impact of sexual abuse is complicated, because relationships with close family members often
it produces multifaceted effects on a variety of precede suicide. A controlled study indicated
outcomes, such as suicide, depression and post- that low levels of communication between par-
traumatic stress disorder. ents and children may act as a significant risk
factor. 4 In this study, other factors such as fami-
Loss
ly discord, lack of family warmth, and dis-
Loss event is confirmed to be a significant risk turbed parent-child relationships were associat-
factor for suicide. 20 Particularly, the loss of a ed with child and adolescent psychopathology,
significant other would place the survivors in a but did not play an especially important role in
high risk situation for suicide. Studies on suicide. A survey of 986 Korean adolescents
bereavement have confirmed that mortality is showed dysfunctional family dynamics to be
increased in surviving spouses. 21 People with more prevalent in the suicide attempters than in
marked dependency needs will be especially the non-attempters. 25
frustrated following a loss, due to the simultane- A constellation of psychopathologies involv-
ous frustration of security needs. Necessarily, ing parental and sibling substance abuse, vio-
parental loss due to separation, divorce, illness, lence and antisocial personality disorder are
or death in children or adolescents would serve associated with the suicide or suicide attempts
as a very potent risk factor for suicide. In a of children. 6,26 It is not clear whether these fam-
study investigating parental loss as a risk factor ily histories indicate a genetic vulnerability or
for suicide, the suicidal patients had experienced environmental stressors, or a combination of
maternal loss significantly more frequently than these two.
the non-suicidal patients. 22 Moreover, the age of More interestingly, a family history of com-

17
 Suicide and psychosocial factors

pleted suicide was found to increase the suicide family instability, such as moves, death, loss of
risk. 27 Family, twin, and adoption studies con- relatives, and the illness of significant caretak-
sistently found that suicidal behavior aggre- ers are suggested to increase the likelihood for
gates in families. 28 Maternal suicide attempts, suicidal behavior among children.
especially, was suggested to be one of the Moreover, legal and disciplinary problems are
strongest predictors of adolescents' suicide found to be associated with an increased risk of
attempts, along with other factors such as the suicide, even after adjusting for psychiatric dis-
substance abuse of fathers and family discord. 29 orders.31
It is unclear if genetic factors play a role in
Environmental influence
mediating the familial transmission of suicide
or if the observed familial clustering is caused Suicide can be precipitated by exposure to real
by the effect of shared environmental factors. 28 or fictional accounts of suicide, such as encoun-
Moreover, a family history of suicidal behavior tering news of another person’s suicide and read-
remained a significant risk factor when the ing about a suicide portrayed in a romantic light
effect of parental psychopathology was statisti- in a book.6 Vulnerable teenagers are particularly
cally controlled for, suggesting that the effect at risk and it is reported that the risk lasts for
of family suicide history is independent of the approximately two weeks after the exposure.32
familial clustering of psychiatric disorders .
Facilitating factors
Stressful life events
Impairment in social adjustment before a sui-
Stressful life events often precede a suicide or cide attempt was introduced as one of the
suicide attempt.4,6 The occurrence of recent life strongest risk factors for the re-occurrence of
events was very high, affecting up to 80% of the suicidal behaviors. 24 Various indices of poor
suicidents. 30 The loss of one’s home, failure in social adjustment were suggested to have an
studies, unemployment, financial difficulties association with suicidal behavior in children
and bankruptcy are common negative life events and adolescents: dysfunctional relationships
among people who commit suicide. The impor- between children or adolescents and family
tance of these adverse life events lies in their members, poor social skills, poor leisure skills,
action as a catalyst in the suicidal process. etc.17
Likewise, the association between stressful Factors contributing to “hopelessness”, such
life events and suicidal behavior was reported in as a negative view about one’s own competence,
children. A follow up study for suicide attempts poor self-esteem, and a sense of responsibility
among prepubertal inpatients with suicidal for negative events have been repeatedly found
ideation indicated that a high rate of stressful to be associated with suicidality.6 Inappropriate
life events served as an important risk factor for copying styles such as impulsivity or catastro-
further suicide attempts. The authors suggested
24 phizing would also lead to suicidal behaviors.33
that life event stresses in the preschool years
Social integration
increase the risk for future suicidal behavior.
Early and chronic life event stresses that lead to After examining suicide beyond the micro

18
 Lee SI & Jung HY

level, Durkheim suggested that “anomie”, who died as a result of suicide: underlying psy-
wherein the bond between the individual and chological distress or mental illness; recogniz-
the community is too weak, is an important fac- able mental health or adjustment difficulties
tor in influencing suicide. 34 Living in a before the suicide attempt; severe stress or life
deprived area or single person household is crisis that often centers around the breakdown
generally associated with a high suicide rate. of an emotional or supportive relationship; dis-
This phenomenon serves as a good example of turbed or unhappy family and childhood back-
social fragmentation as a strong predictor of grounds; socially and educationally disadvan-
suicide. 35 In a national register-based study of taged background. Recently, in a case-control
adult suicides in Korea, lower social class was psychological autopsy of 150 victims of sui-
found to constitute a high risk for suicide, even cide, the following factors were suggested to
after controlling for variables such as age, mari- mediate suicide: unemployment, indebtedness,
tal status, and area of residence. 36
being single, a lack of social support, psychi-
atric illness, and a history of past attempts. 38
The authors indicated that both psychosocial
Discussion
and clinical factors mediate the suicide risk
In summary, recent or past adverse life events, independently. The effect size of the psychoso-
such as physical and sexual abuse and loss of cial factors was suggested to be comparable
significant others were identified as the key risk with that of previously reported psychiatric dis-
factors for suicidal behavior. Family discord orders. 4,39
or a low level of communication and family Although, no single risk factor or any combi-
violence are other important risk factors. nation of the above items is admitted to identify
Additionally, a family history of suicide has an definitely or to a useful degree the future suici-
independent effect on suicide and/or suicidal dal behaviors in suicide attempters, 40 various
attempt along with parental psychopathology. risk factors may combine together to lead to sui-
Therefore, these familial, social, and environ- cidal behavior. For example, when a person with
mental factors which imply a significant act an active disorder (e.g., mood disorder or sub-
leading to suicidal behaviors need to be routine- stance use disorder) encounters a stressful event,
ly asked about in the assessment of suicide which is often caused by an underlying condi-
attempters. tion (loss, humiliation, trouble with law or at
Whether psychosocial risk factors act inde- school, etc.), an acute mood change (anxiety,
pendently on suicide and/or suicide attempt is hopelessness, anger) occurs, leading to a suici-
another debatable aspect. Various social and dal ideation. At that point, an underlying trait
environmental factors were investigated along (for example, impulsivity) or a lack of social
with familial factors or psychiatric illnesses. support could facilitate the suicidal ideation
For example, in a comprehensive research by leading to a real suicidal act.6
the Canterbury Suicide Project in New In conclusion, to understand the individual
Zealand, 37 the authors reported the following risk factors for suicide within an integrative per-
shared circumstances associated with people spective is important. Clinicians need to assess

19
 Suicide and psychosocial factors

not only the interactions between the individual sion and suicidality. J Am Acad Child Adolesc
and family at the micro level, but also the inter- Psychiatry 1999; 38:1490-1496.

actions between the individual and the larger 8. Fergusson DM, Horwood LJ, Lynskey MT.
environmental context. Psychosocial risk fac- Childhood sexual abuse and psychiatric disor-
der in young adulthood, II: psychiatric out-
tors, such as acute or chronic stressors, facilita-
comes of childhood sexual abuse. J Am Acad
tors of suicide, and the background factors
Child Adolesc Psychiatry 1996; 35:1365-1374.
involved in suicide must be considered in a
9. Molnar BE, Shade SB, Kral AH, Booth RE,
comprehensive context, along with the mental or
Watters JK. Suicidal behavior and sexual/physi-
pathological states and the biological vulnerabil- cal abuse among street youth. Child Abuse Negl
ity of the individual. 1998; 22:213-222.

10. Paolucci EO and Violato C. A meta-analysis of

the published research on the effects of child
References
sexual abuse. J Psychology 2001; 135 (1):17-
1. Korean Statistical Information System. Change 36.
in populations, Statistics 2004. Available from: 11. Silverman AB, Reinherz HZ, Giaconia RM. The
http://kosis.nso.go.kr/. long-term sequelae of child and adolescent
2. Suh T. Current situation and trends of suicidal abuse: a longitudinal community study. Child
death, ideas and attempts in Korea. Korea Abuse Negl 1996; 20:709-723.
Institute for Health and Social Affairs, 2000. 12. Bagley C, Wood M, Young L. Victim to abuser:
Available from:http://www.kihasa.re.kr/html/ Mental health and behavioral sequels of child
jsp/main.jpg. sexual abuse in a community survey of young
3. Moscicki EK. Epidemiology of completed and adult males. Child Abuse Negl 1994; 18:683-
attempted suicide: Toward a framework for pre- 697.
vention. Clin Neurosc Res 2001; 1:310-323. 13. Frazier PA and Cohen BB. Research on the sex-
4. G o u l d M S , F i s h e r P , P a r i d e s M , F l o r y M , ual victimization of women: Implications for
Shaffer D. Psychosocial risk factors of child counselor training. Counseling Psychologist
and adolescent completed suicide. Arch Gen 1992; 20 (1):141-158.
Psychiatry 1996; 53:1155-1162. 14. Seng MJ. Child sexual abuse and adolescent
5. Adams KS. Environment, psychosocial, and prostitution: A comparative analysis. Adoles-
psychoanalytic aspects of suicidal behavior, In: cence 1989; 24 (95):665-675.
Suicide over the Life Cycle. Ed. by Blumenthal 15. Garnefski N and Arends E. Sexual abuse and
SJ, Kupfer DJ. Washington, DC, American adolescent maladjustment: differences between
Psychiatric Press, 1990, pp 39-96. male and female victims. J Adolesc 1998; 21
(1):99-107.
6. AACAP Official Action. Practice parameter for
the assessment and treatment of children and 16. Statham DJ, Heath AC, Madden PA, Bucholz
adolescents with suicidal behavior. J Am Acad KK, Bierut L, Dinwiddie SH, Slutske WS,
Child Adolesc Psychiatry 2001; 40 (suppl Dunne MP, Martin NG. Suicidal behavior: an
7):24S-51S. epidemiological and genetic study. Psychol Med
1998; 28:839-855.
7. Brown J, Cohen P, Johnson JG, Smailes EM.
Childhood abuse and neglect: specificity of 17. J a c o b s e n L K , R a b i n o w i t z I , P o p p e r M S ,
effects on adolescent and young adult depres- Solomon RJ, Sokol MS, Pfeffer CR. Interviewing

20
 Lee SI & Jung HY

prepubertal children about suicidal ideation and and psychiatric disorders: a nested case-control
behavior. J Am Acad Child Adolesc Psychiatry study based on longitudinal registers. Lancet
1994; 33 (4):439-452. 2002; 360 (9340): 1126-1130.

18. Christoffersen MN, Poulsen HD, Nielsen A. 28. Pfeffer CR, Normandin L, Kakuma T. Suicidal
Attempted suicide among young people: risk children grow up: relations between family psy-
factors in a prospective register based study of chopathology and adolescents' lifetime suicidal
Danish children born in 1966. Acta Psychiatr behavior. J Nerv Ment Dis 1998; 186 (5):269-
Scand 2003; 108 (5):350-358. 275.

19. Kendall-Tackett KA, Williams LM, Finkelhor 29. Brent DA, Perper JA, Moritz G, Liotus L,
D. Impact of sexual abuse on children: A review Schweers J, Balach L, Roth C. Familial risk fac-
and synthesis of recent empirical studies. tors for adolescent suicide: A case-control
Psychol Bull 1993; 113 (1):164-180. study. Acta Psychiatr Scand 1994; 89:52-58.

20. Cheng AT, Chen TH, Chen CC, Jenkins R. 30. Kolves K, Varnik A, Schneider B, Fritze J,
Psychosocial and psychiatric risk factors for Allik J. Recent life events and suicide: A case-
suicide. Case-control psychological autopsy control study in Tallinn and Frankfurt. Soc Sci
study. Br J Psychiatry 2000; 177:360-365. Med 2006; 62 (11): 2887-2896.

21. Schaefer C, Quesenberry CP Jr, Wi S. Mortality 31. Brent DA, Perper JA, Moritz G, Baugher M,
following conjugal bereavement and the effects Roth C, Balach L, Schweers J. Stressful life
of a shared environment. Am J Epidemiol 1995; events, psychopathology and adolescent suicide:
141:1142-1152. a case control study. Suicide Life Threat Behav
1993; 23:179-187.
22. Botsis AJ, Plutchik R, Kotler M, van Praag HM.
Parental loss and family violence as correlates 32. Bollen KA and Phillips DP. Imitative studies: a
of suicide and violence risk. Suicide Life Threat national study of the effects of television news
Behav 1995; 25 (2):253-260. stories. Am Sociol Rev 1982; 47:802-809.

23. Maris RW. Social and familial risk factors in 33. Brent DA. The aftercare of adolescents with
suicidal behaviours. Psychiatr Clin North Am deliberate self-harm. J Child Psychol Psychiatry
1997; 20:519-550. 1997; 38 (3):277-286.

24. Pfeffer CR, Klerman GL, Hurt SW, Kakuma T, 34. Durkheim E. Suicide: a study in sociology
Peskin JR, Siefker CA. Suicidal children grow [translation by Spalding J, Simpson G]. London:
up: rates and psychosocial risk factors for sui- Routledge and Kegan Paul, 1952.
cide attempts during follow-up. J Am Acad
35. Saunderson T, Haynes R, Langford IH. Urban-
Child Adolesc Psychiatry 1993; 32:106-133.
rural variations in suicides and undetermined
25. Kim HS. Correlation between personality, fami- deaths in England and Wales. J Pub Health Med
ly dynamic environment and suicidal attempt 1998; 20:261-267.
among Korean adolescents population. J Korean
36. Kim MD, Hong SC, Lee SY, Kwak YS, Lee CI,
Acad Nursing 2002; 32 (2):231-242.
Hwang SW, Shin TK, Lee SM, Shin JN. Suicide
26. Pfeffer CR, Normandin L, Kakuma T. Suicidal risk in relation to social class: A national regis-
children grow up: suicidal behavior and psychi- ter-based study of adult suicides in Korea,
atric disorders among relatives. J Am Acad 1999-2001. Int J Soc Psychiatry 2006; 52 (2):
Child Adolesc Psychiatry 1994; 33:1087-1097. 138-151.

27. Qin P, Agerbo E, Mortensen PB. Suicide risk in 37. Beautrais A. Suicide in New Zealand II: a
relation to family history of completed suicide review of risk factors and prevention. N Z Med

21
 Suicide and psychosocial factors

J 2003; 116 (1175): U461. 39. Shaffer D, Gould MS, Fisher P, Trautman P,
Moreau D, Kleinman M, Flory M. Psychiatric
38. Chen EY, Chan WS, Wong PW, Chan SS, Chan
diagnosis in child and adolescent suicide. Arch
CL, Law YW, Beh PS, Chan KK, Cheng JW,
Gen Psychiatry 1996; 53:339-348.
Liu KY, Yip PS. Suicide in Hong Kong: a case-
control psychological autopsy study. Psychol 40. P o k o r n y A D . S u i c i d e p r e d i c t i o n r e v i s i t e d .
Med 2006; 36 (6):815-825. Suicide Life Threat Behav 1993; 23:1-10.

22